Change in Dysfunctional Beliefs About Sleep in Behavior Therapy,Cognitive Therapy,and Cognitive-Behavioral Therapy for Insomnia

As part of a larger randomized controlled trial, 188 participants were randomized to behavior therapy (BT), cognitive therapy (CT), or cognitive-behavioral therapy (CBT) for insomnia. The aims of this study were threefold: (a) to determine whether change in dysfunctional beliefs about sleep was related to change in sleep, insomnia symptoms, and impairment following treatment; (b) to determine whether BT, CT, and CBT differ in their effects on dysfunctional beliefs; and (c) to determine whether the treatments differ in their effects on particular kinds of dysfunctional beliefs. Beliefs, sleep, insomnia symptoms, and sleep-related psychosocial impairment were assessed at pretreatment, posttreatment, and 6- and 12-month follow-up. Greater change in dysfunctional beliefs occurring over the course of BT, CT, or CBT was associated with greater improvement in insomnia symptoms and impairment at posttreatment and both follow-ups. All groups experienced a significant decrease in dysfunctional beliefs during treatment, which were sustained through 6- and 12-month follow-up. Compared with the BT group, a greater proportion of participants in the CT and/or CBT groups endorsed dysfunctional beliefs below a level considered clinically significant at posttreatment and 12-month follow-up. The results demonstrate the importance of targeting dysfunctional beliefs in insomnia treatment, suggest that beliefs may be significantly modified with BT alone, and indicate that cognitive interventions may be particularly powerful in enhancing belief change.     

Acceptance and Commitment Therapy for Treatment-Resistant Posttraumatic Stress Disorder: A Case Study

An adult woman with chronic posttraumatic stress disorder (PTSD) and major depressive disorder who was nonresponsive to 20 sessions of cognitive behavior therapy (CBT) is presented in this case study. Two months after her CBT trial, she was treated with 21 sessions of Acceptance and Commitment Therapy (ACT) for PTSD. Measurements of PTSD severity, depression, anxiety, psychological flexibility and trauma-related thoughts and beliefs were taken at pretreatment, after Sessions 8 and 16, and at posttreatment. Results showed significant reduction on all measures throughout treatment, except for trauma-related thoughts and beliefs, which did not decrease until near the end of treatment. Strengths, limitations, and future directions are discussed.     

The role of sleep-related beliefs to improvement in early cognitive behavioral therapy for insomnia

The aim of this investigation was to examine whether sleep-related beliefs, and reductions in such beliefs and attitudes, were related to clinical improvements in sleep and daytime symptoms after cognitive behavioral therapy (CBT). In total, 64 patients with a short history of insomnia (3-12 months) who had participated in a randomized controlled trial with a 1-year follow-up and received CBT were included. With stepwise multiple regression analyses, sleep-related beliefs were linked to clinical improvements in sleep (five outcomes) and daytime symptoms (seven outcomes). Results indicated that sleep-related beliefs played a small predictive role in clinical improvements in sleep and daytime symptoms after CBT group treatment. Sleep-related beliefs were predictive of treatment response only with regard to sleep efficiency and sleepiness. Reductions in sleep-related beliefs were, however, differently related to improvements in sleep and daytime symptoms. Reductions in such beliefs were consistently linked to improvements in daytime symptoms (7-14% of the variance) but not to sleep improvements (except for sleep quality). In all, this might suggest that sleep-related beliefs play a slightly different role in insomnia than previously envisioned.     

Obsessive beliefs predict cognitive behavior therapy outcome for obsessive compulsive disorder

Cognitive accounts of obsessive compulsive disorder (OCD) assert that core beliefs are crucial to the development, maintenance, and treatment of the disorder. There are a number of obsessive beliefs that are considered fundamental to OCD, including personal responsibility, threat estimation, perfectionism, need for certainty, importance of thoughts, and thought control. The present study investigated if pretreatment severity of obsessive beliefs, as well as the change in obsessive beliefs following treatment, predicted intensive, residential cognitive behavioral therapy (CBT) treatment outcome. A series of hierarchical regression analyses were carried out to investigate the relations between obsessive beliefs and treatment outcome. Results indicated that inflated pretreatment responsibility/threat estimation beliefs were significantly related to less overall obsessive compulsive (OC) symptom reduction at discharge, explaining 2% of the overall variance. Changes in obsessive beliefs broadly, and importance/control of thoughts specifically, were positively related to overall OC symptom reduction at discharge, respectively explaining 18% and 3.6% variance. Results are modestly consistent with a number of theoretical models, which argue that inflated responsibility, threat estimation, and thought control are important to the maintenance and treatment of OCD.     

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy

Despite the major advances in the development of treatments for bulimia nervosa, drop-outs and a lack of engagement in treatment, continue to be problems. Recent studies suggest that the transtheoretical model of change may be applicable to bulimia nervosa. The aim of this study was to examine the roles of readiness to change and therapeutic alliance in determining engagement and outcome in the first phase of treatment. One hundred and twenty five consecutive female patients meeting DSM-IV criteria for bulimia nervosa took part in a randomised controlled treatment trial. The first phase of the sequential treatment compared four sessions of either cognitive behavioural therapy (CBT) or motivational enhancement therapy (MET) in engaging patients in treatment and reducing symptoms. Patients in the action stage showed greater improvement in symptoms of binge eating than did patients in the contemplation stage. Higher pretreatment scores on action were also related to the development of a better therapeutic alliance (as perceived by patients) after four weeks. However, pretreatment stage of change did not predict who dropped out of treatment. There were no differences between MET and CBT in terms of reducing bulimic symptoms or in terms of developing a therapeutic alliance or increasing readiness to change. The results suggest that the transtheoretical model of change may have some validity in the treatment of bulimia nervosa although current measures of readiness to change may require modification. Overall, readiness to change is more strongly related to improvement and the development of a therapeutic alliance than the specific type of treatment.     

University students’ views about compatibility of cognitive behaviour therapy (CBT) with their personal,social and religious values (a study from Pakistan)

Cognitive behaviour therapy (CBT) in its current form might not be applicable in non Western cultures. Differences between Western and non Western cultures have been reported widely. Psychotherapy was developed in the West and is underpinned by many beliefs which might be specific only to the Western culture. However, in order to modify CBT, we need to understand whether the concepts associated with the CBT might cause conflicts among people who receive therapy. This study explored the beliefs of the university students in Pakistan to find out if the concepts underpinning CBT are consistent with the personal, family, socio-cultural and religious values of the university students. Discussions were held with University students in Rahim Yar Khan, Pakistan. Students were given information on various aspects of the CBT and were asked to rate their agreement with these concepts on a visual analogue scale. There was little disagreement for the principles of CBT for personal values, while some disagreement existed for religious values. This study highlights the value of assessing peoples’ beliefs about acceptability of CBT in non Western cultures. Students in Pakistan felt that the principles of CBT are consistent with their belief system in most areas. However, the value system of students might not be representative of the rest of the population.     

Somatoform dissociation in eating-disordered patients

This study investigated the role of somatoform dissociation in eating disorders and pathological eating behaviour, relative to the established association of eating pathology with psychological dissociation. The participants were 131 women with DSM-IV diagnoses of anorexic or bulimic disorders and 75 women who had no such disorder. Each woman completed measures of psychological and somatoform dissociation, as well as a measure of bulimic attitudes. The current presence or absence of specific bulimic behaviours was identified during the clinical interview. Levels of both forms of dissociation were higher in the women who had diagnoses of disorders with a bulimic component (bulimia nervosa; anorexia nervosa of the binge/purge subtype) than in the non-clinical or restrictive anorexic women. Somatoform dissociation showed particularly strong links with the presence of bulimic behavioural features (excessive exercise, laxative abuse, diet pill abuse, diuretic abuse) and with bulimic attitudes. The formulation and treatment of cases where there are bulimic features is likely to be enhanced by the assessment of somatoform dissociation.     

The role of maladaptive beliefs in cognitive-behavioral therapy: Evidence from social anxiety disorder

Beliefs that are negatively biased, inaccurate, and rigid are thought to play a key role in the mood and anxiety disorders. Our goal in this study was to examine whether a change in maladaptive beliefs mediated the outcome of individual cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD). In a sample of 47 individuals with SAD receiving CBT, we measured maladaptive interpersonal beliefs as well as emotional and behavioral components of social anxiety, both at baseline and after treatment completion. We found that (a) maladaptive interpersonal beliefs were associated with social anxiety at baseline and treatment completion; (b) maladaptive interpersonal beliefs were significantly reduced from baseline to treatment completion; and (c) treatment-related reductions in maladaptive interpersonal beliefs fully accounted for reductions in social anxiety after CBT. These results extend the literature by providing support for cognitive models of mental disorders, broadly, and SAD, specifically.     

Individual and group CBT and IPT for Puerto Rican adolescents with depressive symptoms

This study compared individual (I) to group (G) formats of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for the treatment of depression in adolescents. One hundred and 12 Puerto Rican adolescents were randomized to four conditions (CBT-I, CBT-G, IPT-I, IPT-G). Participants were assessed at pretreatment and posttreatment with structured interviews to establish diagnosis and with self-report measures to assess treatment outcome. The results suggest that CBT and IPT are robust treatments in both group and individual formats. However, CBT produced significantly greater decreases in depressive symptoms and improved self-concept than IPT. The implications of these findings are discussed.     

Does emotional reasoning change during cognitive behavioural therapy for anxiety?

Emotional reasoning refers to the use of subjective emotions, rather than objective evidence, to form conclusions about oneself and the world. It is a key interpretative bias in cognitive models of anxiety disorders and appears to be especially evident in individuals with anxiety disorders. However, the amenability of emotional reasoning to change during treatment has not yet been investigated. We sought to determine whether emotional reasoning tendencies change during a course of routine cognitive-behavioural therapy (CBT). Emotional reasoning tendencies were assessed in 36 individuals with a primary anxiety disorder who were seeking treatment at an outpatient clinic. Changes in anxiety and depressive symptoms as well as emotional reasoning tendencies after 12 sessions of CBT were examined in 25 individuals for whom there was complete data. Emotional reasoning tendencies were evident at pretreatment assessment. Although anxiety and depressive symptoms decreased during CBT, only one of six emotional reasoning interpretative styles (pertaining to conclusions that one is incompetent) changed significantly during the course of therapy. Attrition rates were high and there was not enough information regarding the extent to which therapy specifically focused on addressing emotional reasoning tendencies. Individuals seeking treatment for anxiety disorders appear to engage in emotional reasoning, however routine individual CBT does not appear to result in changes in emotional reasoning tendencies.     

Cognitive-behavioural therapy for adolescents with bulimic symptomatology: The acceptability and effectiveness of internet-based delivery

Background

The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited.

Aims

To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology.

Method

101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions (‘Overcoming Bulimia Online’), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined.

Results

There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive.

Conclusions

The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.     

Parent Accommodation Contemporaneously Mediates the Association Between Youth Irritability and Youth Anxiety Treatment Outcome

Research documents that child and adolescent (youth) irritability and anxiety have high co-occurrence, and anxious-irritable presentations are associated with greater impairment than anxious nonirritable presentations. This study examines the association between irritability and youth anxiety treatment outcome and tests a conceptual model of the associations among youth irritability, parent accommodation, and youth anxiety severity following cognitive behavioral treatment (CBT). Participants were N = 128 clinic-referred youths ages 6 to 17 years (M = 9.76 years; 57% female) who met criteria for primary anxiety disorder diagnoses and completed a 12- to 14-week CBT anxiety protocol. Parent- and youth-report on youth irritability, parent accommodation of their child’s anxiety, and youth anxiety severity were assessed pretreatment and posttreatment. Using parent-report, youth irritability at pretreatment was associated with high parent accommodation of youth anxiety and high youth anxiety severity at posttreatment. The association between irritability and youth anxiety outcome was mediated contemporaneously by parent accommodation at posttreatment. These findings show that parent accommodation of their anxious-irritable children’s anxiety may account for high youth anxiety severity following treatment. Developing strategies to target irritability in anxious youth and/or reduce parent accommodation in the presence of youth irritability represent important directions for future research.     

Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms

The purpose of the present study was to examine the potential efficacy, patient acceptability, and feasibility of a novel, cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. Thirty-one adults with ADHD and stable psychopharmacology for ADHD were randomized to CBT plus continued psychopharmacology or continued psychopharmacology alone. Assessments included ADHD severity and associated anxiety and depression rated by an independent evaluator (IE) and by self-report. At the outcome assessment, those who were randomized to CBT had lower IE-rated ADHD symptoms (p < .01) and global severity (p < .002), as well as self-reported ADHD symptoms (p < .0001) than those randomized to continued psychopharmacology alone. Those in the CBT group also had lower IE-rated and self-report anxiety (p's < .04), lower IE-rated depression (p < .01), and a trend to have lower self-reported depression (p = .06). CBT continued to show superiority over continued psychopharmacology alone when statistically controlling levels of depression in analyses of core ADHD symptoms. There were significantly more treatment responders among patients who received CBT (56%) compared to those who did not (13%) (p < .02). These data support the hypothesis that CBT for adults with ADHD with residual symptoms is a feasible, acceptable, and potentially efficacious next-step treatment approach, worthy of further testing.     

Sleep-Related Safety Behaviors and Dysfunctional Beliefs Mediate the Efficacy of Online CBT for Insomnia: A Randomized Controlled Trial

Several trials have demonstrated the efficacy of online cognitive behavioral therapy (CBT) for insomnia. However, few studies have examined putative mechanisms of change based on the cognitive model of insomnia. Identification of modifiable mechanisms by which the treatment works may guide efforts to further improve the efficacy of insomnia treatment. The current study therefore has two aims: (1) to replicate the finding that online CBT is effective for insomnia and (2) to test putative mechanism of change (i.e., safety behaviors and dysfunctional beliefs). Accordingly, we conducted a randomized controlled trial in which individuals with insomnia were randomized to either online CBT for insomnia (n = 36) or a waiting-list control group (n = 27). Baseline and posttest assessments included questionnaires assessing insomnia severity, safety behaviors, dysfunctional beliefs, anxiety and depression, and a sleep diary. Three- and six-month assessments were administered to the CBT group only. Results show moderate to large statistically significant effects of the online treatment compared to the waiting list on insomnia severity, sleep measures, sleep safety behaviors, and dysfunctional beliefs. Furthermore, dysfunctional beliefs and safety behaviors mediated the effects of treatment on insomnia severity and sleep efficiency. Together, these findings corroborate the efficacy of online CBT for insomnia, and suggest that these effects were produced by changing maladaptive beliefs, as well as safety behaviors. Treatment protocols for insomnia may specifically be enhanced by more focused attention on the comprehensive fading of sleep safety behaviors, for instance through behavioral experiments.     

Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia?

Dysfunctional beliefs and attitudes about sleep are presumed to play an important mediating role in perpetuating insomnia. The present study evaluated the impact of cognitive-behavioral and pharmacological treatments for insomnia on sleep-related beliefs and attitudes and the relationship between those changes and sleep improvements. The participants were older adults with chronic and primary insomnia. They received cognitive-behavior therapy (CBT), pharmacotherapy (PCT), combined CBT+PCT (COMB), or a medication placebo (PLA). In addition to daily sleep diaries and sleep laboratory measures, the participants completed the dysfunctional beliefs and attitudes about sleep scale (DBAS) at baseline and posttreatment, and at 3-, 12- and 24-month follow-up assessments. The results showed that CBT and COMB treatments produced greater improvements of beliefs and attitudes about sleep at posttreatment than PCT and PLA. Reductions of DBAS scores were significantly correlated with improvements of sleep efficiency as measured by daily sleep diaries and by polysomnography. In addition, more adaptive beliefs and attitudes about sleep at posttreatment were associated with better maintenance of sleep improvements at follow-ups. These findings highlight the importance of targeting sleep-related beliefs and attitudes in the treatment of insomnia.     

Extreme thinking in clinically depressed adolescents: Results from the Treatment for Adolescents with Depression Study (TADS)

The purpose of this report is to examine relations between extreme thinking, as measured by the Dysfunctional Attitudes Scale, and the maintenance of gains among adolescents who participated in the Treatment for Adolescents with Depression Study (TADS). We examine extreme thinking among 327 adolescents (mean age = 14.56, 57% female, 75% White) who received cognitive behavior therapy (CBT), fluoxetine (FLX), or a combination of CBT and FLX (COMB). Among those who met remission status on the Children’s Depression Rating Scale - Revised (CDRS-R ≤ 28; 56 at week 12, 79 at week 18) extreme thinking did not predict failure to maintain remission. This is in contrast to findings with depressed adults. Treatment influenced level of extreme thinking, and this appeared to be driven by greater endorsement of positively valenced beliefs as opposed to a decrease in negatively valenced beliefs. Developmental or investigation characteristics may account for the discrepancy in findings.     

Emotion-Focused Cognitive-Behavioral Therapy for Youth with Anxiety Disorders: A Randomized Trial

Difficulties with emotion regulation are a core feature of anxiety disorders (ADs) in children and adults. Interventions with a specific focus on emotion regulation are gaining empirical support. Yet, no studies to date have compared the relative efficacy of such interventions to existing evidence-based treatments. Such comparisons are necessary to determine whether emotion-focused treatments might be more effective for youth exhibiting broad emotion-regulation difficulties at pretreatment. This study examined an emotion-focused cognitive-behavioral therapy (ECBT) protocol in comparison to traditional cognitive-behavioral therapy (CBT) in a sample of children with a primary anxiety disorder diagnosis. Moderation analyses examined whether children with higher levels of emotion dysregulation at pretreatment would show greater levels of improvement in ECBT than CBT. Ninety-two youth ages 7 to 12 years (58% male) with a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia were included. Participants were randomly assigned to ECBT or CBT. Results showed that youth in both conditions demonstrated similar improvements in emotion regulation and that pretreatment levels of emotion dysregulation did not moderate treatment outcomes. Additional analyses showed that ECBT and CBT were similarly effective on diagnostic, severity, and improvement measures. Future work is needed to further explore the ways that emotion regulation is related to treatment outcome for anxious youth.     

A Randomized Trial of Cognitive Behaviour Therapy and Cognitive Therapy for Children with Posttraumatic Stress Disorder Following Single-Incident Trauma

The present study compared the efficacy of trauma-focused cognitive behavior therapy (CBT) with trauma-focused cognitive therapy (without exposure; CT) for children and youth with posttraumatic stress disorder (PTSD). Children and youth who had experienced single-incident trauma (N = 33; 7–17 years old) were randomly assigned to receive 9 weeks of either CBT or CT which was administered individually to children and their parents. Intent-to-treat analyses demonstrated that both interventions significantly reduced severity of PTSD, depression, and general anxiety. At posttreatment 65% of CBT and 56% of the CT group no longer met criteria for PTSD. Treatment completers showed a better response (CBT: 91%; CT: 90%), and gains were maintained at 6-month follow-up. Maternal depressive symptoms and unhelpful trauma beliefs moderated children’s outcome. It is concluded that PTSD secondary to single-incident trauma can be successfully treated with trauma-focused cognitive behavioural methods and the use of exposure is not a prerequisite for good outcome.     

Exposure Therapy Beliefs and Utilization for Treatment of PTSD: A Survey of Licensed Mental Health Providers

Exposure-based therapies for posttraumatic stress disorder (PTSD) and anxiety disorders remain underutilized, despite their effectiveness and widescale dissemination efforts. This study surveyed a broad range of licensed providers (N = 155) to examine rates at which prolonged exposure (PE) and other interventions are used to treat PTSD and to investigate provider characteristics linked to exposure beliefs and utilization. While 92.3% of clinicians reported understanding of or training in exposure, only 55.5% of providers reported use of PE to treat PTSD. Clinicians with current cognitive behavioral therapy (CBT) orientation, CBT training orientation, a doctoral degree, and training in PE endorsed greater likelihood of exposure utilization for PTSD (ps < .001, ds = 0.82–1.98) and less negative beliefs about exposure (ps < .01, ds = 0.55–2.00). Exposure beliefs also differed based on healthcare setting (p < .001). Among providers trained in exposure (n = 106), master’s degree and non-CBT current theoretical orientation were associated with high utilization yet also negative beliefs. Results suggest exposure training, accurate beliefs, and utilization still lag among some groups of providers. Additionally, negative beliefs and misunderstanding of the exposure rationale may persist even among providers who are trained and report high utilization.     

Emotion Beliefs and Cognitive Behavioural Therapy for Social Anxiety Disorder

Despite strong support for the efficacy of cognitive behavioural therapy (CBT) for social anxiety disorder (SAD), little is known about mechanisms of change in treatment. Within the context of a randomized controlled trial of CBT, this study examined patients' beliefs about the fixed versus malleable nature of anxiety—their ‘implicit theories’—as a key variable in CBT for SAD. Compared to waitlist (n = 29; 58% female), CBT (n = 24; 52% female) led to significantly lower levels of fixed beliefs about anxiety (M_baseline = 11.70 vs. M_Post = 7.08, d = 1.27). These implicit beliefs indirectly explained CBT-related changes in social anxiety symptoms (κ² = .28, [95% CI = 0.12, 0.46]). Implicit beliefs also uniquely predicted treatment outcomes when controlling for baseline social anxiety and other kinds of maladaptive beliefs (perceived social costs, perceived social self-efficacy, and maladaptive interpersonal beliefs). Finally, implicit beliefs continued to predict social anxiety symptoms at 12 months post-treatment. These findings suggest that changes in patients' beliefs about their emotions may play an important role in CBT for SAD.